My thoughts on how to run a green health service. Ensuring that we put the planet and people above the desires of big business and understanding the place for health care with the cycle of life. These are my thoughts and do not necessarily reflect the opinions of any organisations that I belong to! Make sure that you set your RSS reader to: http://greenhealthservice.blogspot.com/atom.xml

Sunday, July 29, 2007

Interesting piece from Energy Bulletin on the readiness of UK dentistry for peak oil! The British Dental Association published a document called "Dental Futures – forward to 2020" which failed to mention the words: energy, oil, sustainability or carbon.

"Dentistry in the UK and around the world has a long way to go before it can even start a discussion about dental care in a post peak oil world."

Saturday, July 28, 2007

This is a transcript of a speech that I gave at the House of Commons's Grand Committee Room on 24/7/07. This was part of a panel discussion with Frank Dobson, Norman Lamb and Neal Watson...

Thank you for giving me the opportunity to set out the Green perspective of what would be in this 'new prescription for the NHS'. I suspect that you may be asking what the Greens have to say on health care and I hope that I can show you that we have a very clear vision that sets us apart from others, and that we have a deep commitment to the NHS and its principles.

For example, we have been campaigning alongside the Keep Our NHS Public campaign for the past year or so, with many of our members joining local KONP groups, knocking on doors and organising petitions. It is worth remembering that we are the only main party that is fundamentally opposed to private sector involvement in health care.

In defining this new prescription for the NHS and where health care should go over the next 20 years, there are a number of key areas.

Firstly, I think the top priority that we must address is accountability. We currently have a health care system that spends £90 billion of taxpayers money, a system that accounts for about 9% of our GDP, results is 5% of vehicle journeys and therefore 5% of all vehicle pollution [1], yet it is under the dictatorial control of just one person, the secretary of state.

We all know that staff, patients, the public, local councillors, MPs and even ministers, don't get listened to. Last year we had Hazel Blears, John Reid and Jacqui Smith that were among 13 ministers protesting at cuts, including a health minister, Ivan Lewis [2]. We, not only have no accountability to local people for their services, but this lack of accountability exists at every level. We have also witnessed the decline of the Community Health Councils into Patients' fora, and now further decline into something called 'LINKS'. There is only one good solution to freeing the NHS of centralist dictates and for providing true accountability to and involvement with local people and that is to have the NHS accountable to local government.

Of course, if people want to have no say in health care, if people want to have no accountability, if people want the NHS to do its own thing, then we should opt for the arms length quango that seems to be flavour of the month. But if we want to have a real voice in our local health care services then we need to have direct accountability to local people through local government.

But shouldn't the NHS be led by clinicians? Well, we need clinicians to develop new approaches to health care and to develop new healthcare technology. We need clinicians to advise on the best and safest way to provide services. But just because something is deemed to be clinically right, it may not be what local people want or need and we must not forget that the NHS is there to serve them.

Accountability has been reduced further by the purchaser / provider split, the internal market, that the NHS operates. When you subcontract work you reduce your responsibility, it gives you the ability to say, “it wasn't me but I'll get on to them”. But with this reduction in responsibility come less accountability. The NHS tries hard to mitigate this problem with its various service reviews, but sub contracting any service, be it cleaning, independent sector treatments or foundation trust hospitals, brings problems when trying to hold them to account.

I am also sure that we are all well aware of the intensely destructive and expensive nature of the NHS market. We now have Payment by results and practice based commissioning, where 'money follows the patient' and every visit is costed and paid for, but health care is not a object to be bought and sold. In a civilized society health care should be a right not a commodity. 'From each according to his ability, to each according to his needs' - not according his, or his PCT's, ability to pay.

So, what are the alternatives to the internal market? We have already had a far superior model to the purchaser / provider split. Directly funded and managed health care was provided at a fraction of today's costs and at the same time the NHS was seen as the best in the world. Sure, wages were too low and health care technology wasn't as advanced, but we have seen a 50% increase in funding since then much of which is wasted on administering our flawed Americanised model.

We hear from the big corporate proponents of marketisation that markets deliver new ideas and advances in health care. I say that is rubbish - it is clinicians that come up with new ideas and advances and they do this for their patients and because they have a natural desire to improve care. UK clinicians are pushing the frontiers of health care because they feel it is the right thing to do, they don't do it to get a bigger market share. New methods of health care need to be driven by NHS staff as does the weeding out of outdated and unsafe practice. Clinicians need to drive clinical change.

But staff, patients and the public are missing this relentless march towards the US model. Let us not forget, the US model leaves millions with no access to health care yet costs twice as much as much as the UK! So why on earth are we trying to emulate it?

The NHS was founded upon a universal service for all based on clinical need, not ability to pay. It was founded as a health service to be funded by taxation. Rather than continuing in the current direction towards the US model, we must recapture the core values that the NHS was built upon.

Were you aware that the government recently consulted on changing its core principles for the NHS? Previously it had set out 10 principles in the NHS plan, one of which said: “Public funds for healthcare will be devoted solely to NHS patients.”. The new principles, proposed of course by Labour, leave this line out... and how could they leave it in while millions of pounds are going to private companies' shareholders?

We do need to re-examine the core values and ensure that they are fit for the 21st century. For example there is nothing in them which talks of timeliness of access to health care [3]. According to the current set of principles patients could wait years for treatment without going against the values of the NHS. There is also nothing in them about providing services to local people and communities. Putting values at the heart of health care, values at the forefront of any changes, must be paramount. Perhaps we ought to use core values as the key measures of performance rather than some of the weird targets currently in place.

Funding is another of the central themes of health care debates. Currently about one fifth of public spending is on health care - around £90 billion, or about a grand and a half for every citizen. But people don't know what the cost of health care is. On the one hand we have protests against spending cuts, on the other we have complaints about taxation.

It is time to reconcile these. We need to be honest and open about just how much health care costs and the best way to do this is to have an NHS Tax that people can see and relate to. Obviously this would not increase the overall tax burden but would simply re-badge part of our current direct taxes. The implications of this are wide reaching there would be an increased sense of ownership of the service as well as the acknowledgment of just how much health care costs.

Ok, so what does a green health service look like, what is our prescription for a new NHS? I've talked of accountability, principles, values and funding but what model of health care do we think NHS needs?

The principle of localisation not centralisation is one that flows through green philosophy. The arrival of climate change, and the pending arrival of peak oil, serve to increase the importance of making health care as local as possible. We do applaud Labour's polyclinic ideas - these have been Green Party policy for years. Community health centres with a wide range of health care functions serving communities are an excellent model. Cuba adopted the polyclinic model 30 years ago and now has one of the best health care services in the world.

It should be up to local people to decide the set up of health care services for their area, but as a general model / principle we support a four tier system of community services, GPs, polyclinics and hospitals. Polyclinics need to be underpinned by GPs, and polyclinics, in turn, need to support district hospitals.

There is, however, a very real and worrying trend that needs urgent and sensible debate. The increasing centralisation of specialist health care is not a sustainable model. A 'network' approach to specialist services is fine, but the notion that we should only provide high tech health care services on a regional basis needs to be balanced by damage it does to local services, and of course the environment, as well as the difficulties it causes for vulnerable people having to travel great distances.

The argument that a service is not safe unless it is provided centrally can be taken to extreme lengths. At what point will we decide to have just the one full A&E service in the country? It would be very high tech, well staffed and probably tick all the governance boxes, but it would be of no use to most people.

It should be for local people to decide what level of risk that they want to have in their health care services and if people want a local A&E that doesn't see enough people to tick every clinical governance box then so be it - whose risk is it to take? We urgently need a sensible debate on how we can best serve local people.

Finally, I was asked to comment on what I think GB should do in his first 100 days... I'd like to suggest that he starts to buy back the hospitals that he has spent the last 10 years selling off through PFI.

It doesn't go nearly far enough though. It does talk about green transport plans, using renewables, recycling more which are all great, but I think it misses the fundemental shift in think that is required.

For example, with 5% of all traffic being related to health care, simply putting in park and ride schemes is hardly likely to make a dent. The report does mention the closer to home strategy and suggests that it will reduce travelling. Frustratingly, there has been no study to see if this is true or not (or no study that I am aware of). Certainly patients recouperating in a local community hospital close to their relatives will be benficial (although this would need to be measured against potentially poorer energy efficiency of the smaller hospital). But what about intensive support at home? Plenty of staff driving round all day visiting patient to help them stay at home. Good for patient care, but is it good for the environment? We desparately need answers to these questions.

The report also doesn't enter the debate about increasing specialisation and centralisation of services and how they increase travel. We need a sensible debate about what we want and how far away we want it!

Sunday, July 15, 2007

"While blogging is part of the Web 2.0 revolution, it only gives the illusion of true interactivity. Why? Sure the content is dynamic, and readers can interact with the author and (to a limited extent) other readers by leaving comments at the end of a post. But there is no true reader to reader interaction: While there is a GROUP led by the blog author, there is no COMMUNITY."And to face and overcome the challenges posed by peak oil, climate change and other looming calamities, we need more than such a group. We do need a true community (or NETWORK) of like-minded individuals willing to share information, ideas, problems and solutions. And through the magic of modern technology, we can achieve this vision."

Tuesday, July 10, 2007

Great article here by Daniel Bednarz who discusses the reliance of health care on oil. He states that the US model of health care, where the affluent Americans go for a 'Ferrari' model of health care and are in worse health than the UK 'Honda' model.

He seems to be saying that there needs to be a move away from hi-tech medicine and a focus on public health...

Sunday, July 8, 2007

Providing a definition of inactivity is not straightforward as the health benefits of exercise vary according to the amount of exercise taken, and have been considered to be dose responsive (Irwin, 2003). There is, however, clear guidance as to a recommended level of activity from Heath Development Agency (2000) who suggest 30 minutes of moderate exercise five times a week for adults. The Centre for Disease Control and Prevention (2003) agree with this but also suggests that inactivity is "not engaging in any regular pattern of physical activity beyond daily functioning" (Centre for Disease Control and Prevention, 2003, p1). Clearly there is agreement about how much activity is desirable, but little notion as to when a person might be considered inactive, for example, it would seem nonsensical that if a person only manages 149 minutes of moderate exercise in a week they are sedentary. Suggesting that an inactive person is one who does no more activity than through their general daily functioning takes no account of people who have built moderate activity into their routine, for example if daily life requires a cycle ride to work, the person is clearly not sedentary. It would, therefore, seem appropriate to look at levels of activity on a fairly individual level, rather than as time spent in a gym.

The evidence to suggest that moderate exercise gives health benefits is compelling. Rutter (2003), on behalf of the Public Health Observatory, suggests the risk of coronary heart disease (CHD), stroke, hypertension, cancers, diabetes, depression and cognitive functioning all benefit from moderate exercise, and the Health Development Agency (2002) add a reduction in obesity and osteoporosis to the list. Rutter (2003) goes on to suggest that preventable deaths from CHD alone that can be attributed to a sedentary lifestyle are around 85,000 per year in the UK . Although there are no estimates as to the preventable deaths by other causes due to sedentary lifestyles, as the increased risk of stroke is threefold, compared to twofold for CHD, and stroke being the UK's third biggest killer, it is likely to be of a significant size. Estimates from the US are of a smaller magnitude with Jones et al (1997) suggesting 250,000 deaths per annum. The 1998 Health Survey for England (Department of Heath, 1998) found that only 37% of men and 25% of women were exercising to the recommended levels and that this level dropped with age and in Black and minority groups.

There has been a multitude of studies looking at the relative risks and benefits of exercise. Irwin (2003) examined the effects of 90 minutes exercise per week on women aged 50 - 70 years and found significant weight loss and reductions in body fat. Hu et al (2003) looked at inactivity by US women over a six year period, and found that for each 2 hours per day of watching television increased the risk of obesity by 23% and diabetes type II by 14%. Hu et al (2003) also found that an hour per day of brisk walking reduced the risk of obesity by 24% and diabetes by 30%. Ebbeling (2002) suggested that television watching and obesity is associated by both the inactivity and through increases food consumption during this period. The Ahmed et al (2003) reported that rises in childhood obesity has meant a fall in life expectancy for the first time in 140 years and although extent of causes of this increase in obesity are not clear, they obviously involve exercise levels as well as food consumption.

The Department of Health (1999) aimed to save 300,000 lives through health improvements, and the evidence suggests that exercise levels have a huge impact in mortality as well as morbidity (Rutter, 2003), however the Department of Health seems keen to raise the profile of other public health issues above that of exercise in its performance indicators for public health (Commission for Health Improvement, 2003). In light of the lack of emphasis put on inactivity, it must therefore be considered what impacts can be made on the levels of exercise by public health practitioners.

Beattie (1991) proposed two continuums to health promotion, working with from an individual level to a community level, and from the initiative for change coming from people, "negotiated" or from the state, "authoritative". This model leads to four areas that public health practitioners can be involved in, traditional health education persuasion techniques, personal counselling with clients to health them develop their own health choices, through to working with communities to help them make changes to their health and finally to legislative action centrally. These four areas seem to encompass the variety of roles the public health practitioners can be involved in.

Lawlor et al (1999) studied primary care professional's attitudes to health promotion, and reported that only 33% of general practitioners (GPs) felt there was strong evidence linking sedentary lifestyles with early death. They also found that 30% of GPs did not feel knowledgeable enough to give advice and only 8% gave opportunistic advice to patients. Steptoe (1999) compared GPs with practice nurses and found that only 20% of GPs felt that personal counselling for lifestyle advice was effective compared with 54% of practice nurses, and that 70% of GPs did not think that targeting health promotion to patients with low exercise levels was important. Schemes to enable primary care practitioners to enable patients to access exercise, typically through local leisure centres have been in existence for some time (Health Development Agency, 1998a), but whilst practice nurses see health promotion as part of their role, and feel that it is effective, GPs do not. There is little evidence on the effectiveness of a one to one health promotion approach to exercise, with most schemes, especially those involving gyms, show little sustainable lifestyle change with participation falling after the initial enthusiasm; the exception to this are those schemes that promote walking, particularly brisk walking (Health Development Agency, 2001). There is seems to be little research on how effective public health practitioners can be in persuading GPs to understand the importance of exercise, or even to what extent this is happening, but clearly there is a need for this. With front line health professionals not accepting the importance of exercise or the effectiveness of health promotion, there is little chance of this knowledge being imparted to patients. There appears to be very little evidence as to the cost effectiveness of this approach, although given the problems with sustainability, the cost of leisure centre admission and the time involved counselling by health professionals, the relative costs are likely to be high. There is a further issue with the elderly, as traditional forms of exercise promotion does not suit them (Drewnowski, 2001).

Beattie's (1991) continuums suggest that health improvements can be effected at a community level, which can be from either a "top down", authoritative approach or led by the community to make changes. There seem to be two aspects to improving the physical activity levels within communities, promoting exercise as an addition to day-to-day living, such as visiting gyms and encouraging sports, but also ensuring that aspects of daily life are changed to incorporate exercise. Transport is the most obvious area of this second aspect, increasing car usage is associated with reduced physical activity levels (Turbin et al, 2002) and clearly one option to improve exercise levels would be to reverse this trend.

Fergusson (1999) felt that a range of measures is needed to change behaviour in relation to travel. The Health Development Agency (2001) agrees with this and suggests that local authorities need to be deeply involved with this. There is a need to ensure that people have the ability to make journeys by foot or cycle, and this means that when local authorities plan for services they need to take this into account. Out of town shopping centres and hospitals may allow little opportunity for travel other that by car or bus, which increases inactivity, aside from the knock-on effects of social exclusion, pollution and the decline in community (Rutter, 2003). Van Diepan (2000) found that car usage was associated with lower population densities, i.e urban sprawling, and walking increases as the density of the population rises. It seems obvious that in order to encourage shorter travel distances, local authorities need to understand health, through working with public health professionals, in order to consider impacts to health when making planning decisions. Ensuring that partnerships between health and local authorities are fundamental, allowing health impact assessments to inform planning decisions and for health needs assessments to assist in the local authority's strategic plans.

Whilst it seems essential that local planning is required to ensure that it becomes possible to access services without reliance on cars, this in itself would need to be augmented by other measures to encourage healthy travel. There have been concerns about how safe it is for children to walk to school or for cycling in general. This perception clearly needs addressing and can be managed with the introduction of cycle lanes and traffic calming measures (Mackie and Wells, 2003). Again, these are areas that are under the control of local authorities, but if the highways departments are not working in partnership with planning and health then getting schemes to aid the promotion of healthy travel to work and schools will prove difficult. It is also necessary to involve employers in these schemes. Ensuring that the workplace has opportunities for showering and changing, may well be a crucial factor in an individual's decision to cycle to work (Health Development Agency, 1998b), clearly no one would want to remain in sweaty clothes!

The promotion of cycling and walking to work and school has been shown to be an effective way of increasing exercise levels ( Department for Transport, 2000). Clearly there needs to be a drive by health promoters and primary care professionals, including those in occupational health, to encourage people to adopt alternative, sustainable, forms of exercise. The public health professionals who span health and social services have very clear roles in ensuring that the elements of this form of exercise are in place.

It may be that a community lead impetus to make the changes required for healthy alternatives to travel would be unlikely, given the public's passion for the car (Hathaway, 2000). Those being socially excluded, through lack of access and transport, may not have the political power to motivate communities into action to provide for some of the wide ranging changes required. It seems important to ensure that the clear and pragmatic alternatives to travel are lead by the authoritative corner of Beattie's (1991) model, allowing for individuals and communities to adopt these changes. Seedhouse (1997) in his discussions on health promotion, suggests that health promotion is concerned with societal values and driven by politics to encourage social order and cohesion rather that trying to ensure that individuals are somehow saved from unhealthy habits. Perhaps in the case of sustainable exercise through travel, it needs to be acknowledged that a top down lead is required.

To conclude, it has been shown that there is a good consensus as to the optimal level of activity, and to the vast benefits to both mortality and morbidity that it confers, but there is no agreement as to at which point inactivity is defined. With estimates in excess of 85000 early death due to inactivity and the majority of the population not taking the recommended level of exercise, there is the potential to clear health improvements to be made. There is a great deal of work to be done in raising the level of knowledge in health professionals, as their own understanding of this area is poor. Schemes to encourage exercise, based on education and encouragement to use local leisure centres, have not been shown to be cost effective and do not give a sustainable approach to lifestyle change. Encouraging brisk walking and cycling are the areas that have been shown to provide long term lifestyle change and it has been shown that one way of doing this is through promoting alternative modes of transport to work and school. This requires a partnership approach involving, planning, highways, health professionals and employers, to ensure that the barriers to this are removed and that this form of exercise is encouraged. Whilst there are opportunities for health promotion within each of Beattie's (1991) areas, perhaps encouraging exercise needs to be led politically to ensure that the partnership working removes the barriers appropriately.

Beattie, A. (1991) Knowledge and Control in Health Promotion: a Test Case for Social Policy and Social Theory; in Gabe J, Calnan M. and Bury M. (editors) (1991) The Sociology of the Health Service Routledge

Turbin J, Lucas L, Mackett R and Paskins, J (2002) The Effects of Car Use on Children's Physical Activity Patterns , Centre for Transport Studies, University College London Online:- Available at http://www.cts.ucl.ac.uk/pdf/HEPA.pdf (21.11.03)

Thursday, July 5, 2007

From Paul Roth's Blog on Peak Oil and the effect that it will have on health care: "The ability of a short-term fuel disruption to cause a health-care crisis was demonstrated in the United Kingdom in September of the year 2000."

This piece is in two parts, the second is available here. Paul talks about the need for fuel shortage plans, similar to the Energy Decent Action Plans being worked up by the Transition Towns Groups.

"In contrast, peak oil will not only limit oil-based transportation, but it will disrupt the manufacture of everything containing petrochemicals (ie all plastic, synthetic clothing, kitchen appliances, computers). They will not be sitting in warehouses waiting for normality to resume. They will not be there in the first place. So energy descent will not present a transportation challenge. Secondly, the crisis ended in just over a week, allowing things to get back to normal quickly. Peak oil will be permanent, and there will be no quick fix."

About Me

I have a beautiful wife Dawn and equally beautiful daughter, Poppy. I am a qualified nurse and a keen interest in the politics of health care. I am deeply committed to Green politics and have a keen interested in the spiritual side of philospohy.